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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application.` <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Tragsferablcl;`Revocable, Suspendable) <br /> ENVIRONMENTAL'REALTH•PERMIT PUMP&WELL <br /> (COMPLETE-IN TRIPLICATE) WATER QUALITY y <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County OrdiiWce No. 1862 and-the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /v .Cs�� City/Town �6�i* <br /> Owner's Name 7e{4,2� GSC/ rr» Phane Apr-��ct Isa �� � .t <br /> _ �� [�G 7 1 <br /> Address /v City <ty I <br /> Contractor'sName c� Ae le' <br /> se#_���/z3 Business Phone�6�=,/�, -7 <br /> Contractor's Address a-4-0 00 /� Z_ L✓ Rrp Mency Phone Q <br /> Is Certificate of Workman's Compensation Insurance on File dith SJLHD? Yes No 11c- - 'V <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines /S-b Pit Privy Jrf6Ale = t <br /> Sewage Disposal Fielddy/✓� Cesspool/Seepage Pit 4AD� Other of-J-0^✓P! } <br /> Property Line Private Domestic Well 11 Public Domestic Well 0 nJ (# <br /> INTENDED USE TYPE OF WELL r <br /> ri + <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation (� <br /> -DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal =f <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout:.Jne 7e- <br /> 0 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL / Surface Seal installed By: -� he / <br /> PUMP INSTALLATION: Contractor e7d G izi, r'AV 5:7 <br /> Type of Pump 077 0 An H.P. /p <br /> PUMP REPLACEMENT: ❑ State Work Donei' <br /> PUMP REPAIR: ❑ State Work Done- <br /> DESTRUCTLON OF WELL: Well Diameter _ -_ Approximate Depth # <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work'will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit i <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grou spection prior to grouting and a final inspection. <br /> Signed X Title: & — Date: 7 <br /> I (Draw Plot Plan on Reverse Side) <br /> l <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> -Application Accepted By - � x -- «y - — -- — Date�J <br /> Additional Comments: _ <br /> Phase II Grout Inspection �. Ph a IH Final In'spectton <br /> Inspection By Date Inspection By pate�� y k <br /> Fee.Is Due: ❑ ANNUALLY El PER UNIT 1:1 PER SITE E] EACH ❑ January 1 &Received By January 31 ❑ Judy 1 &Received By July 3i <br /> BILLING REMITTANCE $ REMIT-- <br /> i BASE - EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT/ <br /> _ FEES <br /> " LESS 10 d9Z „ <br /> ',r PRORATION <br /> PLUS F <br /> �PENALTY <br /> i <br /> '—OTHER <br /> OTHER <br /> Received ey - Dater Receipt No Permit No. lissuante Date Mailed Del e <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE;,P.O.Box 2009 STOCKTON,CA 95201 <br />